Hands at Work Lois Carlson, aTRIL Pamela Means Wilson, aTRIL Connecticut Combined Hand Services, Inc. Hartford, Connecticut
Hands are tools. Hands are also complex. The human hand is exquisitely designed to interact with the environment in a purposeful manner. Groups of extrinsic and intrinsic muscles cooperate to orchestrate the movement of multiplejoint chains in a stable and agile fashion. Sensory receptors in the skin, joints, and musculotendinous units provide ongoing feedback about the external and internal environments. When a hand is injured, a major tool of the worker's world is affected. Rehabilitation can be as complex as the physical structures that have been i~ured. Recently, rehabilitation of hand injuries has evolved from acute-care programs to work hardening and job-oriented evaluation. Increasingly, therapists are also moving away from the traditional clinic setting to onsite job analysis and the implementation of injury-prevention programs in the industrial workplace. In this article, we present the evolution of one such program that developed in conjunction with a hand surgical practice. We relate how using the skills developed in-house can then be applied to developing injuryprevention programs in industrial settings. The importance of addressing work-related issues from the onset and throughout treatment is emphasized.
EVOLUTION OF THE CLINIC WORK PROGRAM
Connecticut Combined Hand Services was initially established to provide acute care following hand injury and!or reconstructive surgery. Treatment focused on physical parameters, such as range of motion, scar, and edema. Functional assessment was limited to Activities of Daily Living (ADL) checklists, a few standardized dexterity tests, and reported activity level. Treatment depended on well-structured homeactivity programs, a compliant patient, and good communication. Work-related issues even during the acute phase needed to be addressed. These included the following considerations. Loss of the worker role. The individuals suddenly find themselves in the patient role and have lost, at least temporarily, the worker role. The longer they stay in this role, and the more strongly they identify with it, the less likely they are to return to regular employment. The importance of prolonged therapy and repeated surgical procedures must be weighed against the need to return the individual to purposeful activity. The meaning of work. What does the loss of the worker role mean to the patient? For example, is the individual now in the position of taking orders from everyone instead of being in charge? The sense ofloss of control and! or self-esteem may affect the patient's ability to cooperate in therapy. Is the primary concern financial? If so, are secondary gains competing with the patient's motivation to get better and return to work?
58
WORK / FALL 1990
Work-oriented treatment goals. Even during the acute phase, the patient's willingness to comply with therapy will be enhanced if the therapist is aware of the patient's functional goals. For example, the lumberjack who needs to return to work immediately to feed a family will show little motivation to attend daily therapy to gain range of motion in one joint, but may be willing to carry out a well-structured home program. Therapy also needs to focus on increasing strength to minimize time lost from the job. At the other extreme is the violinist who is very concerned about a 10-degree loss of motion, is anxious about the possible loss of a professional career, and may need psychological support as well as an aggressive program to gain every degree possible. Work alternatives. If an injury is serious enough to preclude the return to previous employment, vocational rehabilitation does not have to wait until the final disability rating. Make the patient aware of community resources for vocational retraining and/or job placement. Explore job modifications with the employer-is a lighter job available? Enlist the help of others working with the patient, such as the rehabilitation nurse.
WORK-TOLERANCE SCREENING After several months of working using the acute-care approach, it became all too obvious that an important link was missing between evaluating a patient's range of motion and strength, sending the patient back to the physician for a return-to-work date, and expecting a successful return to work. A more direct approach was needed that would allow for observation of the patient's actual work capacities. Space was a major limiting factor, preventing the addition of new equipment and staff. How could work be evaluated with such limited resources? The development of a work-tolerance screening l (WTS) focused on upper-extremity function became the starting point. With creativity and careful observation, a WTS can be accomplished in the most modest of surroundings. A simple way to get started is
to use the following list of physical demands outlined by the U.S. Department of Labor 2 (DOL) as a general guide. 1. Reaching, handling, and fingering. Reaching can be observed using anything and everything in the clinic, from the floor to the table to the top of the file cabinet. Standardized dexterity tests, such as the Purdue Pegboard Test and the Minnesota Rate of Manipulation Test, are compact enough for the smallest of spaces and can be used to obtain a general sense of the patient's ability to handle and finger objects. The Bennett Hand Tool Dexterity Test and the Crawford Small Parts Dexterity Test are also good for small spaces and provide a means to evaluate the patient's ability to use tools. Work samples may be borrowed from the patient's place of employment or fabricated by the therapist. 2. Feeling. The ability to feel can be evaluated in a functional manner using any dexterity task with vision occluded. 3. Pushing, pulling, lifting, and carrying. All that is needed are weights and something to put them in. Floor to knuckle height, to chest height, to overhead lifting can be simulated simply by using available surfaces, such as chairs, tables, and cabinets. Carrying for any distance may be more problematic, however, hallways or other spaces may sometimes be temporarily borrowed. 4. Other. Additional categories included in the DOL Physical Demands should be addressed at least on an observational level and/or by patient report. These include standing, walking, sitting, climbing, balancing, stooping, kneeling, crawling, crouching, talking, hearing, and vision.
The results of the work-tolerance screening in the clinic with "no room, no staff, no time" can be used as a general guideline for structuring the home program. The therapist must be careful, in reporting this information, to note the limitations of this approach. Reporting fulse-negative results is less likely than reporting
Hands at Work
false-positive results. In other words, it is easier to state that the patient will probably be unable to return to his or her job at the present time than to state with any certainty that he or she can. Use of the work-tolerance screening approach does, however, add an important aspect to the evaluation/treatment process by directing goals of treatment to problem areas related to function.
WORK AS A TREATMENT MODALITY The next stage in the evolution of the clinic was realized after obtaining additional space and staff. A secretary and a physical therapist were added to the original staff of one occupational therapist. The space more than doubled, allowing for the purchase of additional equipment, including the Baltimore Therapeutic Equipment (BTE) Work Simulator. With these additional resources the clinic became a "work laboratory" and work-hardening services were provided. 3 Time and staff, however, failed to keep pace with the expanding list of referral sources in a space that was soon to get cramped rather than cozy. To meet these needs, the clinic again increased in staff, space, and equipment. To be truly effective in providing work-hardening services, the clinic needed at least one designated individual who could monitor the patients for extended periods of time. This person was a certified occupational therapy assistant (corA). The clinic could now provide a full complement of services (including work-related evaluation, work hardening, and work simulation) for up to a full day. The patient's program could now be orchestrated from acute care to return to work with meaningful recommendations to the physician in terms of actual observed work capacity. The team approach has been a vital component of the clinic's work program. Each patient is assigned a case manager (a registered occupational or physical therapist), who evaluates and follows the patient throughout the course of treatment and coordinates the work-hardening program with the occupational therapy assistant.
59
This assistant has a background in activity analysis and a sense of creativity that makes. her the perfect candidate for matching the patient's job specifications to activities in the clinic. In addition to simulating tasks requiring predominantly upper-extremity function, other areas related to work need to be addressed, including cardiopulmonary, back, and lower-extremity status. Although these conditions are not treated as primary diagnoses, long-term patients are often seen with a multitude of problems from lack of normal use. The efforts of occupational and physical therapists working together helps ensure quality of services. Weekly case-manager meetings provide the added structure to the program that allows thoughtful discussion with all members of the team. Sometimes therapists who are not directly treating the patient provide the added insight of someone looking from afar and, perhaps, with a more objective eye. Interactions among patients within the workroom setting can also be used advantageously for support and feedback.
WORK AS A DIAGNOSTIC TOOL Assessment of a patient's functional abilities and work capacities goes hand in hand with any therapeutic work program. The use of work as a diagnostic tool is a variation of this evaluation approach with a different focus. In addition to looking at the patient's ability to do a job, the emphasis is on evaluating the physical response to work to assist with the diagnosis. The use of work as a primary evaluation tool is appropriate, particularly for the chronic patient who has a long history of unsuccessful treatment, no clear diagnosis, or an equivocal clinical evaluation. Being closely linked to a hand surgeon, who is frequently asked to see these "problem" patients, the clinic's work program is now used regularly to help clarify the diagnosis and determine the severity of the problem. The emphasis is on delineating the reasons for the functional limitations, not just on reporting what the patient can or cannot do.
60
W 0 R K / FALL 1990
For example, in a patient with chronic pain who has been protecting the hand, localization of the pain is often difficult. Work helps to separate what is normal from what is abnormal. What is not normal will stand out like a red flag. The patient is then seen with the physician and a plan of action is determined, which may include the need for further therapy or surgical intervention and/or a return to work with appropriate modifications. Having developed these constructs of work on an in-house level, we devote the rest of this article to the evolution of the therapist's role from the clinic to the workplace.
THE REALITY OF THE WORKPLACE A job analysis may be thought of as a systematic approach to observing and describing the duties and conditions of a specific job. Accurate job simulation in the clinic was a frequent frustration stemming from unawareness of actual job tasks in industry. Job analysis is more accurately done when the therapist enters the workplace and sees first-hand the job being performed by a worker. The therapist entering an industry needs to be an active participant in communicating with workers and supervisors, asking questions, and, if permitted, trying out the job.
HOW TO INITIATE A PREVENTION PROGRAM In-House Training To begin learning how to analyze a workplace, start by performing an experimental in-house job-site analysis. We did this as an exercise at our clinic and made minor changes in work stations that minimized pain complaints and stress for our coworkers. Our secretary/receptionist was observed at work for posture, reaching patterns, typing, and filing habits, and was interviewed regarding her comfort on the job, any difficulties with performance of tasks, and what she would change to make her working conditions more suitable. Interventions included an adjustable
chair with better back support, improved lighting at the typewriter, another file cabinet to decrease the resistive pinching in removing files, relocation of bins for easier access, and specific stretching exercises to relieve stressed muscles. 4 ,5 Therapists were observed throughout the course of a day making splints, cutting with shears, doing deep-friction massage, using equipment such as ultrasound, and opening supply boxes. There was a heightened awareness of appropriate use and maintenance of scissors and other equipment, proper body mechanics on the job, and storage location of supplies to improve our work environment. Having done our in-house analysis and designed an appropriate prevention program, we learned that the best way to get an answer was to ask a question, that change can be simple and rewarding, and that making a difference can be confidence-building. The first on-site prevention program can be the hardest and most threatening. The solution is to do it where you feel at home and comfortable. Do it where you work!
WHAT HAVE YOU GOT TO LOSE? Another alternative, or perhaps a follow-up step, would be to do an on-site visit to a local industry free of charge. After deciding to venture out, you may wonder, "How do I get in?" Your patients may be able to help you select an industry to approach. Informally survey your patients regarding existing prevention programs in their plant, open-mindedness of management, and anticipated reception of intervention by coworkers. Once you have identified a viable industry, make the necessary phone calls. A good place to start is the personnel office or medical department. Be honest as to your n~ason for wanting to do this. When entering industry for the first time, limit yourself to observing only a sampling of the jobs in the plant. This will make the visit less overwhelming.
TOOLS OF THE TRADE What are the tools of the trade? Suggested equipment to bring to an on-site visit are a
Hands at Work
portable videocamera (preferably lightweight), tape measure, push-pull gauge, scale for weighing, stopwatch, clipboard, pens, paper, safety goggles, and appropriate footwear (no high heels).6 We have found that when two therapists can go to an on-site visit, one therapist can be responsible for operating the videocamera while the other therapist makes notes and gathers information from workers and supervisors. Both therapists will ask questions and accumulate valuable observations and ideas for change. It is not, however, always possible to have two therapists go on-site. If you are alone, write down as much as you can. Be descriptive in recording the station layout, reach and grasp patterns, and task sequences. Ask the worker what is difficult or awkward and get feedback. The purpose of the visit is to gather information to take back to the clinic for analysis. It is helpful .to have copies of company job descriptions along with any production quotas applicable. Feasibility of changes may be discussed briefly; however, formal recommendations will come at a later date once you have had the time to analyze and review the gathered information. If asked by management about recommendations or changes, it is best to respond in a general sense. For instance, comment on observed difficulties in packing boxes or awkwardness in reaching for items at the work station, and communicate that you need to analyze all the information before making concrete recommendations.
61
CONCLUSION
We have described the evolution of hand-injury rehabilitation from the clinic to the workplace. Experience, however, will dictate how the role the therapist selects will evolve. As one's exposure to industry increases, variations on similar products or workstation designs and layouts will emerge. You will bring with you a body of know1edge about what does and does not work and the ability to envision how effective changes at one industry can be applied to another to produce desired results. By having walked through a previous company's doors, you will immediately become a resource to a new industry. Therapists, with their background in anatomy and physiology, observation skills, and awareness of potential risk factors, are highly qualified to enter industry, perform on-site job analyses, and implement prevention programs. Those therapists with open eyes and minds as well as open-ended questions-therapists who are willing to be active, observant participantswill facilitate change in people and workplaces. In the final analysis, rehabilitation of hand injuries comes down to the success or failure of each patient's therapy. For successful rehabilitation of the injured-hand patient, therapy must be framed by the ultimate functional goal. A return to work is one of these goals. The potential for achieving this goal depends on how you maximize the patient's physical and functional status in the clinic as it applies to your knowledge and understanding of the real world of work.
REFERENCES 1. Matheson LN: Work Capacity Evaluation. Anaheim CA, ERIC, 1984, P 51. 2. u.s. Department of Labor: A Guide to Job Analysis. Menomonie WI, Stout Vocational Rehabilitation Institute, 1982, p 331. 3. Baxter-Petralia PL, Bruening LA, Blackmore SM: Work therapy program of the Hand Rehabilitation Center in Philadelphia. In Hunter JM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand. St. Louis, CV Mosby, 1990, P 1155. 4. Corlett EN: The investigation and evaluation
of work and workplaces. Ergonomics 1988, 31: 727-734. 5. Hansford T, Blood H, Kent B, Lutz G: Blood flow changes at the wrist in manual workers after preventive interventions. J Hand Surg 1986: 503-508. 6. Jacobs K, WyrickJ: Use of Department of Labor references and job analysis. In Hertfelder S, Gwin C (eds): Work in Progress: Occupational Therapy in Work Programs. Rockville MD, American Occupational Therapy Association, 1989, p 43.
Hands are tools. Hands are also complex. The human hand is exquisitely designed to interact with the environment in a purposeful manner. Groups of extrinsic and intrinsic muscles cooperate to orchestrate the movement of multiplejoint chains in a stable and agile fashion. Sensory receptors in the skin, joints, and musculotendinous units provide ongoing feedback about the external and internal environments. When a hand is injured, a major tool of the worker's world is affected. Rehabilitation can be as complex as the physical structures that have been i~ured. Recently, rehabilitation of hand injuries has evolved from acute-care programs to work hardening and job-oriented evaluation. Increasingly, therapists are also moving away from the traditional clinic setting to onsite job analysis and the implementation of injury-prevention programs in the industrial workplace. In this article, we present the evolution of one such program that developed in conjunction with a hand surgical practice. We relate how using the skills developed in-house can then be applied to developing injuryprevention programs in industrial settings. The importance of addressing work-related issues from the onset and throughout treatment is emphasized.
EVOLUTION OF THE CLINIC WORK PROGRAM
Connecticut Combined Hand Services was initially established to provide acute care following hand injury and!or reconstructive surgery. Treatment focused on physical parameters, such as range of motion, scar, and edema. Functional assessment was limited to Activities of Daily Living (ADL) checklists, a few standardized dexterity tests, and reported activity level. Treatment depended on well-structured homeactivity programs, a compliant patient, and good communication. Work-related issues even during the acute phase needed to be addressed. These included the following considerations. Loss of the worker role. The individuals suddenly find themselves in the patient role and have lost, at least temporarily, the worker role. The longer they stay in this role, and the more strongly they identify with it, the less likely they are to return to regular employment. The importance of prolonged therapy and repeated surgical procedures must be weighed against the need to return the individual to purposeful activity. The meaning of work. What does the loss of the worker role mean to the patient? For example, is the individual now in the position of taking orders from everyone instead of being in charge? The sense ofloss of control and! or self-esteem may affect the patient's ability to cooperate in therapy. Is the primary concern financial? If so, are secondary gains competing with the patient's motivation to get better and return to work?
58
WORK / FALL 1990
Work-oriented treatment goals. Even during the acute phase, the patient's willingness to comply with therapy will be enhanced if the therapist is aware of the patient's functional goals. For example, the lumberjack who needs to return to work immediately to feed a family will show little motivation to attend daily therapy to gain range of motion in one joint, but may be willing to carry out a well-structured home program. Therapy also needs to focus on increasing strength to minimize time lost from the job. At the other extreme is the violinist who is very concerned about a 10-degree loss of motion, is anxious about the possible loss of a professional career, and may need psychological support as well as an aggressive program to gain every degree possible. Work alternatives. If an injury is serious enough to preclude the return to previous employment, vocational rehabilitation does not have to wait until the final disability rating. Make the patient aware of community resources for vocational retraining and/or job placement. Explore job modifications with the employer-is a lighter job available? Enlist the help of others working with the patient, such as the rehabilitation nurse.
WORK-TOLERANCE SCREENING After several months of working using the acute-care approach, it became all too obvious that an important link was missing between evaluating a patient's range of motion and strength, sending the patient back to the physician for a return-to-work date, and expecting a successful return to work. A more direct approach was needed that would allow for observation of the patient's actual work capacities. Space was a major limiting factor, preventing the addition of new equipment and staff. How could work be evaluated with such limited resources? The development of a work-tolerance screening l (WTS) focused on upper-extremity function became the starting point. With creativity and careful observation, a WTS can be accomplished in the most modest of surroundings. A simple way to get started is
to use the following list of physical demands outlined by the U.S. Department of Labor 2 (DOL) as a general guide. 1. Reaching, handling, and fingering. Reaching can be observed using anything and everything in the clinic, from the floor to the table to the top of the file cabinet. Standardized dexterity tests, such as the Purdue Pegboard Test and the Minnesota Rate of Manipulation Test, are compact enough for the smallest of spaces and can be used to obtain a general sense of the patient's ability to handle and finger objects. The Bennett Hand Tool Dexterity Test and the Crawford Small Parts Dexterity Test are also good for small spaces and provide a means to evaluate the patient's ability to use tools. Work samples may be borrowed from the patient's place of employment or fabricated by the therapist. 2. Feeling. The ability to feel can be evaluated in a functional manner using any dexterity task with vision occluded. 3. Pushing, pulling, lifting, and carrying. All that is needed are weights and something to put them in. Floor to knuckle height, to chest height, to overhead lifting can be simulated simply by using available surfaces, such as chairs, tables, and cabinets. Carrying for any distance may be more problematic, however, hallways or other spaces may sometimes be temporarily borrowed. 4. Other. Additional categories included in the DOL Physical Demands should be addressed at least on an observational level and/or by patient report. These include standing, walking, sitting, climbing, balancing, stooping, kneeling, crawling, crouching, talking, hearing, and vision.
The results of the work-tolerance screening in the clinic with "no room, no staff, no time" can be used as a general guideline for structuring the home program. The therapist must be careful, in reporting this information, to note the limitations of this approach. Reporting fulse-negative results is less likely than reporting
Hands at Work
false-positive results. In other words, it is easier to state that the patient will probably be unable to return to his or her job at the present time than to state with any certainty that he or she can. Use of the work-tolerance screening approach does, however, add an important aspect to the evaluation/treatment process by directing goals of treatment to problem areas related to function.
WORK AS A TREATMENT MODALITY The next stage in the evolution of the clinic was realized after obtaining additional space and staff. A secretary and a physical therapist were added to the original staff of one occupational therapist. The space more than doubled, allowing for the purchase of additional equipment, including the Baltimore Therapeutic Equipment (BTE) Work Simulator. With these additional resources the clinic became a "work laboratory" and work-hardening services were provided. 3 Time and staff, however, failed to keep pace with the expanding list of referral sources in a space that was soon to get cramped rather than cozy. To meet these needs, the clinic again increased in staff, space, and equipment. To be truly effective in providing work-hardening services, the clinic needed at least one designated individual who could monitor the patients for extended periods of time. This person was a certified occupational therapy assistant (corA). The clinic could now provide a full complement of services (including work-related evaluation, work hardening, and work simulation) for up to a full day. The patient's program could now be orchestrated from acute care to return to work with meaningful recommendations to the physician in terms of actual observed work capacity. The team approach has been a vital component of the clinic's work program. Each patient is assigned a case manager (a registered occupational or physical therapist), who evaluates and follows the patient throughout the course of treatment and coordinates the work-hardening program with the occupational therapy assistant.
59
This assistant has a background in activity analysis and a sense of creativity that makes. her the perfect candidate for matching the patient's job specifications to activities in the clinic. In addition to simulating tasks requiring predominantly upper-extremity function, other areas related to work need to be addressed, including cardiopulmonary, back, and lower-extremity status. Although these conditions are not treated as primary diagnoses, long-term patients are often seen with a multitude of problems from lack of normal use. The efforts of occupational and physical therapists working together helps ensure quality of services. Weekly case-manager meetings provide the added structure to the program that allows thoughtful discussion with all members of the team. Sometimes therapists who are not directly treating the patient provide the added insight of someone looking from afar and, perhaps, with a more objective eye. Interactions among patients within the workroom setting can also be used advantageously for support and feedback.
WORK AS A DIAGNOSTIC TOOL Assessment of a patient's functional abilities and work capacities goes hand in hand with any therapeutic work program. The use of work as a diagnostic tool is a variation of this evaluation approach with a different focus. In addition to looking at the patient's ability to do a job, the emphasis is on evaluating the physical response to work to assist with the diagnosis. The use of work as a primary evaluation tool is appropriate, particularly for the chronic patient who has a long history of unsuccessful treatment, no clear diagnosis, or an equivocal clinical evaluation. Being closely linked to a hand surgeon, who is frequently asked to see these "problem" patients, the clinic's work program is now used regularly to help clarify the diagnosis and determine the severity of the problem. The emphasis is on delineating the reasons for the functional limitations, not just on reporting what the patient can or cannot do.
60
W 0 R K / FALL 1990
For example, in a patient with chronic pain who has been protecting the hand, localization of the pain is often difficult. Work helps to separate what is normal from what is abnormal. What is not normal will stand out like a red flag. The patient is then seen with the physician and a plan of action is determined, which may include the need for further therapy or surgical intervention and/or a return to work with appropriate modifications. Having developed these constructs of work on an in-house level, we devote the rest of this article to the evolution of the therapist's role from the clinic to the workplace.
THE REALITY OF THE WORKPLACE A job analysis may be thought of as a systematic approach to observing and describing the duties and conditions of a specific job. Accurate job simulation in the clinic was a frequent frustration stemming from unawareness of actual job tasks in industry. Job analysis is more accurately done when the therapist enters the workplace and sees first-hand the job being performed by a worker. The therapist entering an industry needs to be an active participant in communicating with workers and supervisors, asking questions, and, if permitted, trying out the job.
HOW TO INITIATE A PREVENTION PROGRAM In-House Training To begin learning how to analyze a workplace, start by performing an experimental in-house job-site analysis. We did this as an exercise at our clinic and made minor changes in work stations that minimized pain complaints and stress for our coworkers. Our secretary/receptionist was observed at work for posture, reaching patterns, typing, and filing habits, and was interviewed regarding her comfort on the job, any difficulties with performance of tasks, and what she would change to make her working conditions more suitable. Interventions included an adjustable
chair with better back support, improved lighting at the typewriter, another file cabinet to decrease the resistive pinching in removing files, relocation of bins for easier access, and specific stretching exercises to relieve stressed muscles. 4 ,5 Therapists were observed throughout the course of a day making splints, cutting with shears, doing deep-friction massage, using equipment such as ultrasound, and opening supply boxes. There was a heightened awareness of appropriate use and maintenance of scissors and other equipment, proper body mechanics on the job, and storage location of supplies to improve our work environment. Having done our in-house analysis and designed an appropriate prevention program, we learned that the best way to get an answer was to ask a question, that change can be simple and rewarding, and that making a difference can be confidence-building. The first on-site prevention program can be the hardest and most threatening. The solution is to do it where you feel at home and comfortable. Do it where you work!
WHAT HAVE YOU GOT TO LOSE? Another alternative, or perhaps a follow-up step, would be to do an on-site visit to a local industry free of charge. After deciding to venture out, you may wonder, "How do I get in?" Your patients may be able to help you select an industry to approach. Informally survey your patients regarding existing prevention programs in their plant, open-mindedness of management, and anticipated reception of intervention by coworkers. Once you have identified a viable industry, make the necessary phone calls. A good place to start is the personnel office or medical department. Be honest as to your n~ason for wanting to do this. When entering industry for the first time, limit yourself to observing only a sampling of the jobs in the plant. This will make the visit less overwhelming.
TOOLS OF THE TRADE What are the tools of the trade? Suggested equipment to bring to an on-site visit are a
Hands at Work
portable videocamera (preferably lightweight), tape measure, push-pull gauge, scale for weighing, stopwatch, clipboard, pens, paper, safety goggles, and appropriate footwear (no high heels).6 We have found that when two therapists can go to an on-site visit, one therapist can be responsible for operating the videocamera while the other therapist makes notes and gathers information from workers and supervisors. Both therapists will ask questions and accumulate valuable observations and ideas for change. It is not, however, always possible to have two therapists go on-site. If you are alone, write down as much as you can. Be descriptive in recording the station layout, reach and grasp patterns, and task sequences. Ask the worker what is difficult or awkward and get feedback. The purpose of the visit is to gather information to take back to the clinic for analysis. It is helpful .to have copies of company job descriptions along with any production quotas applicable. Feasibility of changes may be discussed briefly; however, formal recommendations will come at a later date once you have had the time to analyze and review the gathered information. If asked by management about recommendations or changes, it is best to respond in a general sense. For instance, comment on observed difficulties in packing boxes or awkwardness in reaching for items at the work station, and communicate that you need to analyze all the information before making concrete recommendations.
61
CONCLUSION
We have described the evolution of hand-injury rehabilitation from the clinic to the workplace. Experience, however, will dictate how the role the therapist selects will evolve. As one's exposure to industry increases, variations on similar products or workstation designs and layouts will emerge. You will bring with you a body of know1edge about what does and does not work and the ability to envision how effective changes at one industry can be applied to another to produce desired results. By having walked through a previous company's doors, you will immediately become a resource to a new industry. Therapists, with their background in anatomy and physiology, observation skills, and awareness of potential risk factors, are highly qualified to enter industry, perform on-site job analyses, and implement prevention programs. Those therapists with open eyes and minds as well as open-ended questions-therapists who are willing to be active, observant participantswill facilitate change in people and workplaces. In the final analysis, rehabilitation of hand injuries comes down to the success or failure of each patient's therapy. For successful rehabilitation of the injured-hand patient, therapy must be framed by the ultimate functional goal. A return to work is one of these goals. The potential for achieving this goal depends on how you maximize the patient's physical and functional status in the clinic as it applies to your knowledge and understanding of the real world of work.
REFERENCES 1. Matheson LN: Work Capacity Evaluation. Anaheim CA, ERIC, 1984, P 51. 2. u.s. Department of Labor: A Guide to Job Analysis. Menomonie WI, Stout Vocational Rehabilitation Institute, 1982, p 331. 3. Baxter-Petralia PL, Bruening LA, Blackmore SM: Work therapy program of the Hand Rehabilitation Center in Philadelphia. In Hunter JM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand. St. Louis, CV Mosby, 1990, P 1155. 4. Corlett EN: The investigation and evaluation
of work and workplaces. Ergonomics 1988, 31: 727-734. 5. Hansford T, Blood H, Kent B, Lutz G: Blood flow changes at the wrist in manual workers after preventive interventions. J Hand Surg 1986: 503-508. 6. Jacobs K, WyrickJ: Use of Department of Labor references and job analysis. In Hertfelder S, Gwin C (eds): Work in Progress: Occupational Therapy in Work Programs. Rockville MD, American Occupational Therapy Association, 1989, p 43.
